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Over the past decade, the health services restructuring in many Canadian provinces, often driven by fiscal concerns, has coincided with mental health reform. The mental health system has been criticized for not being comprehensive, for being fragmented with many separate agencies and points of access, for having gaps and duplications of services, and for lacking accountability of services to the overall system (1). Ontario mental heath reform has prompted the closure of provincial psychiatric hospitals and reinvestment of funds into community psychiatric programs. Recently, existing systems that provide integrated and coordinated psychiatric services have been examined, and best practices in mental health care have been suggested (2). Many of these best practices involve provision of psychiatric care to patients with a wide variety of acute, serious mental illnesses within a rapidly responsive service framework. Some suggest that psychiatrist training and practice patterns are inappropriate for a reformed mental health system (3–8). Brooks has suggested that subspecialization in psychiatry has produced clinicians, largely working in urban teaching hospitals, who focus exclusively on a particular diagnosis, often rejecting patients with multiple and mixed problems because they are unsuited for research protocols (4). He also noted that general psychiatrists are urgently required in rural areas, but university training programs, often staffed by subspecialists, neither promote interest in working in underserviced areas nor provide their residents with the necessary skills in general psychiatry. That many psychiatrists working in community-based practices have focused on providing long-term, psychodynamic psychotherapy to patients with personality disorders—in effect abandoning patients with severe and chronic mental disorders—has also been suggested (5,6). Some believe that general psychiatrists need better preparation to assess and treat patients with serious mental illnesses, the focus of reformed mental health system (7,8). Dorian and associates call for development of evidence-based practice guidelines and suggest that psychiatrists cannot continue to recommend treatments based on personal choice and preferred mode of practice (8). Few data exist about the involvement of Canadian psychiatrists in general psychiatry; however, a 1996 Canadian Psychiatric Association (CPA) survey provides information about national demographic and practice patterns (unpublished data). The CPA sent a mail-in questionnaire to all Canadian psychiatrists listed in its provincial registry and to all active CPA members (n = 3628). A total of 1651 psychiatrists responded, for a response rate of 45.5%. Most psychiatrists (72.8%) reported practising in large urban areas. Most identified themselves as having a mixed range of practice (56%), and fewer characterized their practice as solely devoted to adult psychiatry (36.5%), geriatric psychiatry (1.9%), child psychiatry (4.9%), or forensic psychiatry (0.6%). When asked to identify their main practice setting (80% of their time), 38.5% of psychiatrists reported spending 80% or more of their time in a hospital, 27.9% in a private office, 2.3% in an agency, and 29.7% in a mixed or other location. Finally, psychiatrists reported they were seeing patients with serious mental illnesses who demonstrated marked deficits in functioning, with 26% of randomly selected patients and 39% of the most seriously ill patients who were seen the day of the survey having a major psychotic diagnosis, such as schizophrenia or bipolar disorder. Despite concerns about many psychiatrists not treating patients with serious mental illnesses or being affiliated with hospitals, this survey suggests that general psychiatric practice is the focus of a large number of Canadian psychiatrists’ work. Nevertheless, mental health reform and best practices will influence the scope of general psychiatry and the way it is practised in Ontario, thus likely leading to an increased demand for general psychiatrists. We examine recent developments in Ontario’s mental health reform, describe what we consider constitutes general psychiatric services in contrast to tertiary services, suggest guidelines for the training of general psychiatrists, and propose the required changes to develop a truly integrated mental health system (IMHS). Ontario Mental Health Reform and Best PracticesOver the past few years, the 2-part document entitled Making It Happen has guided mental health reform in Ontario. (Part 1 is called “Operational Framework for the Delivery of Mental Health Services and Supports,” and Part 2 is called “Implementation Plan for Mental Health Reform.”) (1). Suggested mental health reform principles include the consumer at the centre of the mental health system, services tailored to consumer needs, improved access to services, services that are linked and coordinated, and services that are based on best practices. Combinations of mental health service functions were identified after it was recognized that patients with various psychiatric problems or, with similar problems at different stages of evolution have different levels of need (9). These levels of need differ in degree of resource intensity, specialization, and service duration. First-line services are provided by front-line health care providers; namely, family physicians, community mental health agencies, community health centres, hospital emergency services, and some hospital-based primary care clinics. First-line services include information and referral services, community crisis telephone lines, and mobile crisis teams. First-line services are targeted toward the general population and service any person with symptoms of mental illness. General hospital psychiatric inpatient and outpatient facilities and some community agencies provide intensive services. These services include inpatient psychiatric services, outpatient services, day hospitals, medication clinics, and community services that provide intensive case management and housing supports. Intensive mental health services are targeted to people with serious mental illness, especially those who are at risk for repeated or prolonged hospitalizations or incarceration. Hospital or community mental health programs provide specialized or tertiary psychiatric services that focus on people who have complex, rare, or unstable mental disorders. This population, a subgroup of people with serious mental illnesses, requires a greater intensity of treatment, rehabilitation, and support than intensive services can provide. Specific groups include the psychogeriatric population, people having comorbid developmental and psychiatric disabilities, patients with schizophrenia who are treatment-resistant or violent, and some patients with complex forensic issues. Specialized services are likely regional programs based in tertiary psychiatric or general hospitals, assertive community treatment (ACT) teams, specialized mobile outreach teams, residential treatment facilities, and regional forensic services. Best practices have been defined as those “activities and programs that are in keeping with the best possible evidence about what works” (2). In a review of best practices, Goering and Associates describe Canadian psychiatric services that demonstrate best practices (2). They suggest that core programs of a reformed mental health system based on best practices should include 1) case management programs; 2) ACT teams; 3) crisis response and psychiatric emergency services; 4) supportive housing and supervised community residences; 5) inpatient and outpatient care, including day hospitalization and home treatment; 6) consumer initiatives including mutual support, advocacy, cultural activities, skills training, economic development, and family self-help groups; and 7) vocational and educational supports. We will need mechanisms to facilitate effective delivery that ensure accountability of mental health programs to consumer needs, that develop shared service models of care for patients with multiple needs, and that improve access to programs and services (1). The Ontario Ministry of Health has decentralized the mental health system management to regional offices, which will evaluate and monitor programs. Performance expectations, program standards, and service benchmarks need to be developed to measure key indicators of patient, program, and system outcomes, such as symptom reduction and quality-of-life measurements. Patient and family satisfaction will be included as outcome. Shared service models will require information sharing and cooperative treatment planning, particularly in areas involving primary care and specialty care partnerships. Formalized shared service agreements will need to be developed for special patient populations with unique needs (the dual diagnosis population). Finally, improved access to programs requires fewer points of entry into the mental health system, provides centralized information and referral functions, facilitates access to psychiatric consultations, and reduces the number of assessments required for patients to receive necessary services. Therefore, the goal of mental health reform is to develop an integrated and coordinated mental health system that provides services to people and that is based on best practices measures (1). Changes in health care delivery due to economic forces have also influenced psychiatric practice patterns and, ultimately, psychiatric training programs in other areas of Canada and in the US. Insurance, hospital, and physician payment structures, for example, have influenced the type and duration of treatments provided, promoting shorter hospitalizations with less intensive inpatient assessment and treatment. Similarly, these payment structures sometimes restrict outpatient care to short-term, symptom-focused treatments rather than allowing long-term, psychodynamic psychotherapy (10). For this reason, those developing general psychiatric services and training programs in general psychiatry must not only respond to changes driven by mental health reform and best practices but also respond to forces driven by economic realities.
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